20051053.pdfDATE RECEIVEU
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS /
CITY ZIP TELEPHONE
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NAME
ADDRESS
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v PERMIT EXPIRES 6//Q!
NUMBER
JOB , SUITEAPT#
ADDRESS
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approvoa
HW Pmm1l Regwrea (3
Street Use Perron Regw,en
EXISTING .. - PROPOSED _ _ .__ Inspection Required O
SiaeKa1K Require ❑
REQUIRED DEDICATION FTUnderground O
Winner re wren 0
METER SIZE LINE SIZE NO. OF FIXTURES I PRV REQUIRED
YES 0 NO ❑
REMARKS t,
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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CITY ZIP TELEPHONE Z
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NAME CBLL#% ENGINEERING REVIEWED BY DATE
ADDRESS RECYCLE REVIEWED BY DATE
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CITE ;IP TELEPHONE PUBLIC �3 -V� Z 1 PUBLIC WORKS REVIEWED ByUS ! BE PRESENT m
STATE LICENSE NUMBER EXqrV PIRATION DATE H K Y FIRE REVIEWED BY ) . A �• RE! ll` T w
oaA S7&-awk z� �o LL �_ -n
VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
PROPERTYT�jAyCOUNT CE Qu �_���� RECD COMPLETED EXEMPT
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U�j� ❑YES ❑ NO 0 jn
(/ / CA# ZONE SIGN AREA HEIGHT m 0
❑ NEW RESIDENTIAL ❑ PLUMBING / MECH ❑ WAIVER ALLOWED PROPOSED ALLOWED PROPOSED Main
COMMERCIAL COMPLIANCE OR ❑ STUDY O C
❑ ADDITION ❑ CHANGE OF USE LOTCOVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.) ==IK
❑ MIXED USE ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR Z rn
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN z , !D
❑ REPAIR ❑ GRADING ❑ FENCE D Z
CYDS ( X FT.) PARKING LOT AREA PLANNING REVIEWED BY DATE
OTHER REQ'D PROVIDED a r =
❑ DEMOLISH `TANK ❑ I
TGARAGE REMARKS 0 �
❑ CARPORT ❑ ROCKERY WALL ❑ FIRE
LER � T
(TYPE OF USE; BUSINESS OR�c{IV IN:
3: M
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NUMBER NUMBER OF C 0)
STDWELLING F 0 9T¢IUCTION OCCUPANT •n O r
STOAIES UNITS/v,_' C rn
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DESCRIBE WORK TO BE DONE
S ECI LINSPECTION CONSULTANT OCCUPANT rb 0)
LOAD rn
REQUIRED O YES z �0—
REMARKS _
GEOTECH REPORT m _
BY: D
STRUCTURAL ) Z
BY
VALUATION _
$ CO)
Description FEE Description FEE z"
HEAT SOURCE LOT SLOPE90 VESTED DATE Plan CITBCIC State Surcharge n
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PLAN CHECK NO: Building Permit City Surcharge
Plumbing Base Fee
,
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
Mechanical
t BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES; ETC.) WILL REQUIRE
SEPARATE PERMISSION. Grading
LU PERMIT APPLICATION: SEE ECDC 19,00.005(A)(5) Engr. Review Recording Fee
CL PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. Ir1SpeCIIOn Plan Chi(. Deposit
l
w. •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
L IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review Receipt #
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND �.
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY Fire Ins ection Total Amt. Due ~�
FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE p
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.* Landscape Insp. Receipt # +,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL I
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF CALL This application is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• Building Official or his/her Deputy: and Fees are paid and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged in space provided
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSA NCE AND RCW 18:27. �A nC� OFFICIALS SIGNATURE D TE
SIGNATURE ER O A DAT�IG�ED it 'iGJ
J S 771-0220
REL ASED BY D
EXT. 1333
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL • FILE • YELLOW • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 / IBC110 / IRC1100 PINK -OWNER • GOLD • ASSESSOR
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